Payroll deduction available! (up to 2 paychecks)

Transcription

1 A Taste of Amish Tradition Saturday, April 22, 2017 Bus departs Riverside Suites parking lot at 6 a.m. Bus departs from Holmes County at 5 p.m. $95/person Payroll deduction available! (up to 2 paychecks) TOUR DESTINATIONS: Lehman s Hardware - Kidron, OH (Eclectic general store) Amish home for family style feast (FREE GIFT - homemade peanut butter whip) Village of Berlin for shopping time (FREE GIFT - quilted potholder) Hershberger Farm and Bakery (FREE GIFT - homemade bread) Walnut Creek Cheese Country Store (FREE GIFT - chunk of baby swiss cheese) Friends & Family Welcome Register at the following locations: Renee Chaskel (Gift Shop), Tanya Marshall (HR), Mindy Rischar (Riverside - PR), Tricia Woodland (Birchaven - HR), Amanda Dysert (Bluffton - Administration) and Darlene DeLaRosa (Independence House) You must submit your trip waiver when you make your payment. Only associates need to sign the waiver - guests are your responsibility. Seats are not reserved until they are paid for and the trip waiver is returned to Corporate PR & Marketing. Trip fees are non-refundable.

2 ASSUMPTION OF RISKS AND RESPONSIBILITY, AND WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT EVENT: DATE: Amish Country Tour Saturday, April 22, 2017 LOCATION OF EVENT: Holmes County, Ohio PRINTED NAME OF PARTICIPANT/RELEASOR: PRINTED NAME(S) OF GUEST(S): In consideration for participating in the EVENT and other valuable consideration, I RELEASOR hereby RELEASE, WAIVE, DISCHARGE, CONVENANT NOT TO SUE and PROMISE TO INDEMNIFY Blanchard Valley Health System and all of its subsidiaries, agents, volunteers, servants, employees (hereinafter referred to as RELEASEES ) from any and all liability, claims, demands, workers compensation benefits, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me or my personal representatives, or to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise, while participating in such EVENT, or while in, on or upon the premises where the activity is being conducted or in transportation to and from said premises. I, RELEASOR, further fully accept all responsibility for my own well being, and my own actions, and assume all risk associated with participating in the EVENT. IN SIGNING THIS RELEASE, I, RELEASOR, ACKNOWLEDGE AND REPRESENT THAT my attendance and participation in the EVENT is completely voluntary and such attendance and participation does not arise within the course and scope of my employment with RELEASEE. I, RELEASOR, FURTHER ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Assumption of Risk and Responsibility, and Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same. Blanchard Valley Heath System reserves the right to ban participants from future events for their failure to follow the BVHS Bus Trip Standards and Code of Conduct, attached hereto as Appendix A. By signing below, I certify that I have reviewed and agree to adhere to the Page 1 of 4

3 Standards and Code of Conduct, and that failure to do so may result in loss of eligibility to participate in future trips. PARTICIPANT/RELEASOR Date - and - Parent must sign if under 18 years old Date - and - Witness must sign Witness name printed Date Office Use Only: Date of Reservation: Number of Seats Purchased: Location Payment Received (circle one): BVH Gift Shop Bluffton Hospital Birchaven Riverside Payment Type (circle one): Payroll Deduction Check Cash Credit Card Sig nature of Associate Receiveing Payment: The signed trip waiver must be submitted with payment and returned to Corporate Public Relations and Marketing for seats to be considered reserved. Seats will not be held until they are paid for and the waiver is received. Pages 3-4 are to remain with the associate registering for the trip. Page 2 of 4

4 APPENDIX A BVHS BUS TRIP STANDARDS AND CODE OF CONDUCT The offenses set forth below are not all-inclusive, but are intended as examples of unacceptable behavior for which BVHS reserves the right to ban future participation in bus trips and events. Any offense that, in the judgment of BVHS, undermines the enjoyment of other trip participants, or places trip participants in danger may be considered unacceptable and jeopardize future participation. Deliberately engaging in any conduct detrimental to the safety and security of other trip participants. Unauthorized possession of a deadly weapon on the trip. Smoking in non-designated areas while on the trip, including during transportation to and from primary destinations. Theft of property, or willfully causing damage to, waste of, or loss of BVHS property or property of other persons, including but not limited to that of other participants. Fighting, issuing threats or other disorderly conduct while on the trip, including during transportation and time spent at destination venues. Unauthorized possession, use, sale, manufacture, and/or purchase of non-prescribed or illegal drugs during the duration of the event. Consumption of alcohol during transport to and from primary destinations. (Please note: legal and responsible consumption of alcoholic beverages is allowed at event venues.) Criminal complaint, arrest, or convictions that occur during the course of the event. Deliberately or negligently engaging in any activity detrimental to the enjoyment of the event for other participants, or activity that has potential to cause harm to participants. Harassment or discrimination, with regard to all applicable laws, including unwanted verbal and/or physical advances, or where such harassment has the purpose or effect of interfering with a participant s enjoyment of the event. Severe impairment through the use of alcohol, intoxicants, or illegal drugs. Soliciting gifts or money from other trip participants. Violation of posted safety, security, health, or fire prevention rules, or otherwise causing a safety hazard or failure to report an unsafe condition during the course of the event. Page 3 of 4

5 Engaging in disruptive or inappropriate behavior while on the trip, including but not limited to using profane and abusive language, gambling, horseplay, practical joking, name-calling, yelling, arguing loudly in a public area, etc. Unauthorized sale of services, merchandise, and raffle tickets, lotteries, etc. Negligent use of property resulting in damage or loss. Unwelcome, intimidating or harassing comments, remarks, conduct or gestures creating an unfavorable environment. Engaging in rude or discourteous behavior. Creating or contributing to unsanitary or unsafe conditions. Failure to report at designated departure times during the course of the event. Page 4 of 4

6 PAYROLL DEDUCTION AUTHORITY FOR BVHS BUS TRIPS BVHS associates who wish to pay for an upcoming BVHS bus trip through payroll deduction should complete the information below. Please note that payroll deduction is not available to associates whose assigned status is Temporary on Call. TOC associates may pay for trip fees using cash, check or credit card only. I, (printed name) hereby authorize Blanchard Valley Health System to deduct from my pay the total amount as indicated below from my next pay checks. Further, I understand if there are not sufficient funds to withhold the entire amount from my next pay checks, my reservation will not be guaranteed and may be sold to another associate. In the event that I separate employment with BVHS prior to this payroll deduction, I authorize BVHS to deduct the entire total balance due from my final pay check. Date of Purchase Number of Tickets Price Per Ticket Total BVHS Employee #: Date: Signature: Page 1 of 1